'Significant increase' in opioids dispensed to Ontario long-term care homes during COVID-19: Study

A new study of opioidsin some long-term care homes in Ontario found there was a "statistically significant increase" in the medication being dispensed during the first year of the COVID-19 pandemic.

But, the researchers note, the study doesn't answer why dispensations were up and it's far too early to conclude that opioid use in long-term care facilities is problematic.

The researchers did two studies, with the first looking at how the pandemic impacted how various kinds of medications were dispensed. The second study, which was released last month in the Journal of the American Medical Directors Association, looked specifically at opioids.

The researchers looked at theprescriptions claims for medication that werecovered for payment by the Ontario Drug Benefit Programin long-term care and nursing homes from March 2017 to March 2021. The researchersusedclinical and health administrative databases for the study.

Theyfound an overall 1.77 per cent increase in opioids being dispensed between March 2020 and March 2021.

Dispensed means that a prescription for the medication was filled by a pharmacy for a resident in a long-term care home.

"Although absolute differences were small, they were more pronounced for residents without dementia or frailty," the researchers wrote.

For example:

• Opioid dispensed to residents with dementia increased by 1.64 per cent, but in people without dementia by 2.28 per cent.
• Opioid dispensed to residents deemed frail increased by 1.25 per cent, but in people who were not frail by 1.93 per cent.

The study's findings are significant because before the pandemic, opioid use was on a downward trend in these facilities, said one of the study's authors Colleen Maxwell, a University of Waterloo professor at the School of Pharmacy and School of Public Health Sciences.

"Initially, the small increase we saw, we thought, well, that's not necessarily inappropriate and then when we did our second study we did see that the increase persisted over the second wave, even during a time when we could hypothesize the stresses and strains might have been less because death had gone down, vaccinations were happening," Maxwell told CBC News.

"That did raise some concerns because, the obvious question is: Are these medications that may have been started appropriately being continued inappropriately?"

Reasons why still need to be investigated

The study did not answer the question about why opioid dispensation was up.

The researchers wrote in the conclusion an in-depth investigation on that angle is still needed, but said possible consequenses of increased opioid use "include a higher risk of falls and worsening frailty among this population."

Maxwell noted there could be legitimate reasons more opioids were dispensed, including that more people were feeling pain, there may have been more fractures or there may have been more need to use them for palliative care.

Dr. Fred Mather, the past president of the Ontario Long Term Care Clinicians and who works in Kitchener, Ont., also cautioned that the study looked at dispensing of opioids,which isn't the same as administering, or giving, the medication to residents.

"I am not aware of any increase in opioid administration, but we can't speak for all [long-term care homes]," he said in an emailed statement.

The researchers acknowledged their study couldn't tell if the dispensed medications were administered, but Maxwell said becausemedications are closely monitored in long-term care homesettings, the researchers felt confident that the dispenseddata likely reflected medications taken by the residents.

Mark Nesbitt, a spokesperson for Ontario's Ministry of Long-Term Care, said the province will review the study's findings "and consider the complex issues it raises."

Two years ago, theministry partneredwith the national non-profit Institute for Safe Medication Practices Canada to look at how to strengthen medication safety in long-term care homes.

"Medication safety in long-term care homes is critically important to the health and well-being of residents," Nesbitt said in an email. "We continue to put the safety and well-being of long-term care residents at the heart of everything we do."

Opioids common for end-of-life care

Mather noted people should also remember the context of the first and second waves of the pandemic, which hit long-term care and retirement homes particularly hard.

He said many facilities increased orders for medications during the pandemic to be proactive and prepared.

"Opioids are a pain medication and reduce pain and unpleasant symptoms.The choices of pain medication, depending on severity and other circumstances, are Tylenol and opioids," he said.

"Opioids are commonly prescribed for use at end of life. There was increased illness and dying caused by COVID in nursing homes in wave one and two and ordering more medications, including opioids, would be part of a care plan."

Theimpact any increase in opioid use had on the mental and physical health of people living in these care homes also needs to be studied, said researchers.

Maxwell said even with some questions in the air, people like those who oversee and monitor medications in long-term care homes, nurses who work in the homes, pharmacists,doctors, family members and the residents themselvesshould be aware of the study'sfindings. The information should be consideredwhen there are discussions about usingopioids.

"I think it's reallymulti-disciplinary decision making involving all of those who provide oversight and care and that does include input from the resident and input from the family," she said.